Health inspection·September 12, 2025

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview, and record review, the facility failed to provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service for 1 of 1 kitchen reviewed for staffing. The facility failed to employ sufficient staff to prepare resident meals resulting in meals not served according to the posted start times for dinner on 9/10/25 and lunch on 9/11/25. This failure could put residents at risk for altered nutritional status and/or weight loss. Findings included: Record review of facility posting Meal Times on 9/10/25, revealed: .Lunch Starts @ 11:00 am Dinner Starts @ 5:00 pm. Record review of facility's grievance logs revealed: 6/10/25 Food was cold 7/15/25 Cold Food Record review of Resident Council Meeting minutes revealed: 5/12/25 .Cold Food.Lunch, Breakfast, Dinner, Always late being served. 6/10/25 .food is cold sometimes. 7/14/25 .food is cold at breakfast. During an interview on 9/10/25 at 2:58 pm, the DM said there was one cook and two dietary aides working (one in each building). The DM further stated the dinner meal was scheduled at 5:00 pm and nurses arrived at the kitchen at 5:00 pm to start distributing meals. At 5:16 pm, [NAME] A was observed serving the first plate. Observation on 9/10/25 beginning at 4:58 pm revealed a nurse arrive at 5:00 pm to the kitchen in the south building to pick up meal trays. At 5:07 pm, a resident was observed pointing out to the state investigator the mealtimes posted outside the kitchen door. At 5:22 pm, the same resident said dinner was late every day. At 5:24 pm, another resident said dinner had been served about 5:15 pm, adding we all want our food at 5 [PM]. At 5:26 pm, another resident said meals were always late and the food had not really been that hot. Further observation revealed meal trays were still being placed on the meal cart at 5:27 pm. Observation on 9/11/25 beginning at 10:54 am revealed [NAME] B preparing the meal service area in the south building. At 11:26 am the first tray was placed on the meal cart. At 11:34 am a resident in the south dining room said she was hungry. At 11:35 am meal trays were delivered to the memory care unit, 35 minutes after scheduled starting time, a resident said I'm very, very, very hungry. Please, I'm very, very, very hungry. At 11:37 am, the same resident said Give me something to eat, please. I'm very hungry, give me something to eat, I need something to eat. At 11:45 am, the meal cart arrived to the 100 hall for residents eating in their rooms, 45 minutes after scheduled starting time. At 11:50 am the meal cart was delivered to the 200 hall, 50 minutes after the scheduled start time and at 11:52 am the meal cart was delivered to the 400 hall, 52 minutes after scheduled start time. At 12:01 pm the first tray was delivered to the dining room, over 1 hour after scheduled start time. At 12:06 pm, meal trays were being delivered on the 600 hall. Observation on 9/11/25 at 12:14 pm, the state investigator received a test tray. The meal received consisted of meatloaf, scalloped potatoes, and carrots. The food looked appealing and was palatable; however, the carrots and meatloaf were at room temperature. During an interview on 9/11/25 at 2:44 pm, a resident said that the meals were normally late. During an interview on 9/11/25 at 3:14 pm, CNA A said the food was usually late. CNA A further stated the residents did complain that the meals were cold or late. Page 1 of 2 675469 675469 09/12/2025 Harmony Care at Floresville 1811 Sixth St Floresville, TX 78114

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 9/12/25 at 1:51 pm, a resident said that the food was sometimes cold, and it arrived late pretty often. During an interview on 9/12/25 at 1:59 pm, RN B said she did not know how often meals were served late but knew that breakfast was scheduled for 7:00 am and lunch started at 11:00 am. RN B further stated that staff started preparing trays until 11:00 am for lunch. RN B said she had helped with tray preparation by adding condiments to the meal trays because the facility was short-staffed. During an interview on 9/12/25 at 2:21 pm, [NAME] B said breakfast was scheduled at 7:00 am, lunch at 11:00 am, and dinner at 5:00 pm. [NAME] B said he considered 10-20 minutes beyond the scheduled meal time late service. [NAME] B further stated residents may be affected by late meal service because they may get upset or frustrated because they were hungry. [NAME] B said he did not know why lunch was served late on 9/11/25. [NAME] B further stated he thought he was on time because he could not look at his phone when in the kitchen. [NAME] B said there was a clock in the kitchen that was 2 minutes behind. During an interview on 9/12/25 at 3:18 pm, the DM said meals were scheduled for 7:00 am, 11:00 am, and 5:00 pm. The DM said he currently helped the kitchen staff with meals to ensure they were served on time. The DM said he had received grievances in the past about the food being cold. The DM further stated he considered late service 5 minutes after the posted meal service time. The DM said late meal service may affect residents, especially those that took medications with meals. The DM said meals were served late every time [NAME] A was working but did not know why. The DM further stated he did not know why dinner was served late on 9/10/25 and lunch service was late on 9/11/25 due to the meatloaf not being the correct temperature. During an interview on 9/12/25 at 3:50 pm, the Administrator said the facility had one hour to serve meals and they were typically not late. the Administrator further stated that on 9/11/25 the meatloaf was not fully cooked at service time. The Administrator said late meal service may affect the residents by having to wait for the meal, they might be really hungry. Record review of facility's policy titled, The Dining Experience: Staff Responsibilities dated 2023, revealed: Policy: The dining experience will enhance each individual's quality of life through person-centered dining.3. The director of food and nutrition services will perform meal rounds routinely to determine if the meals are timely. 675469 Page 2 of 2